SUMMARY OF BENEFITS - HealthTeam Advantage€¦ · SUMMARY OF BENEFITS. HEALTHTEAM ADVANTAGE PLAN I...

HEALTHTEAM ADVANTAGE PLAN I (PPO)HEALTHTEAM ADVANTAGE PLAN II (PPO)

SUMMARY OF BENEFITS

HealthTeam Advantage, a product of Care N’ Care Insurance Company of North Carolina, Inc., is a Medicare Advantage organization with a Medicare contract. Enrollment in HealthTeam Advantage depends on contract renewal. H9808_16_183 Accepted

2017

SUMMARY OF BENEFITSHEALTHTEAM ADVANTAGE PLAN I (PPO)HEALTHTEAM ADVANTAGE PLAN II (PPO)

This is a summary of drug and health services covered by HealthTeam Advantage Health Plan (PPO) January 1, 2017 - December 31, 2017.

The benefit information provided is a summary of what we cover and what you pay. It does not list every service that we cover or list every limitation or exclusion. To get a complete list of covered services, please call us to request the “Evidence of Coverage.”

To join a HealthTeam Advantage PPO Health Plan, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Our service area includes the following counties in North Carolina: Alamance, Guilford, Randolph, Rockingham.

HealthTeam Advantage has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers in our network, you may pay less for your covered services. But if you want to, you can also use providers that are not in our network.

H9808_16_183

2017

HealthTeam Advantage, a product of Care N’ Care Insurance Company of North Carolina, Inc., is a Medicare Advantage organization with a Medicare contract. Enrollment in HealthTeam Advantage depends on contract renewal.

PREMIUMS AND BENEFITS HEALTHTEAM ADVANTAGE PLAN I WHAT YOU

SHOULD KNOWMonthly Plan Premium $0 monthly You must continue to pay

your Medicare Part B premium.

Deductible $0 This plan does not have a deductible.

IN-NETWORK OUT-OF-NETWORKMaximum Out of Pocket Responsibility (does not include prescription drugs)

$3,400 $5,100 The most you pay for copays, coinsurance, and other costs for medical

services for the year.Inpatient Hospital Coverage Days 1-6:

$225 copay per dayDays 7-90:

$0 copay per day

Days 1-7: $400 copay per day


Our plan covers an unlimited number of days for an inpatient hospital stay.

DOCTOR VISITS • Primary Care Physician (PCP) • Specialist

$10 copay$20 copay

$40 copay$50 copay

Preventive Care $0 copay $30 copayEmergency Care $75 copay $75 copay If you are admitted to

the hospital for the same condition within 3 days, the emergency copay is waived.

Urgently Needed Services $30 copay $30 copayDIAGNOSTIC SERVICES/LABS/IMAGING • Diagnostic Radiology Service

(e.g., MRI) • Lab Services ◦ at a lab facility ◦ at outpatient hospital facility

• Diagnostic Tests and Procedures◦ at a lab facility◦ at outpatient hospital facility

• Outpatient X-Rays ◦ included with physician visit ◦ at outpatient facility

$50 - $200 copay

$0 copay$5 copay

$0 copay$5 copay

$5 copay$5 copay

$75 - $250 copay

$10 copay$25 copay

$10 copay$25 copay

$10 copay$25 copay

Prior authorization may be required for some services. Please contact the plan for

more information.

HEARING SERVICES • Medicare Covered Diagnostic

Hearing Exam • Hearing Aid • Routine Hearing Exam

$35 copay

Not Covered$0 copay

$50 copay

Not Covered$30 copay 1 per year

PREMIUMS AND BENEFITS HEALTHTEAM ADVANTAGE PLAN I WHAT YOU

SHOULD KNOWDENTAL SERVICES IN-NETWORK OUT-OF-NETWORK • Oral Exam & Cleaning • Fillings • Complete Dentures

Not CoveredNot CoveredNot Covered


VISION SERVICES • Medicare Covered

Diagnostic Exam • Routine Eye Exam • Eyeglasses (lenses and

frames)/Contact Lenses after Cataract Surgery

$35 copay

$0 copay$0 copay

$50 copay

$30 copay50% of the cost

1 per year.Materials covered up to

Medicare approved limits.

MENTAL HEALTH SERVICES • Inpatient Visit

• Outpatient Group Therapy Visit • Outpatient Individual

Therapy Visit



$40 copay$40 copay

35% of the cost

$60 copay$60 copay

Skilled Nursing Facility (SNF) Days 1-20: $0 copay per day




Our plan covers up to 100 days in a SNF.

REHABILITATION SERVICES • Occupational Therapy Visit • Physical Therapy and Speech

and Language Therapy Visit

$15 copay$15 copay

$40 copay$40 copay

Ambulance $200 copay $200 copay Referral required for non-emergency transportation.

Transportation Not Covered Not CoveredFOOT CARE (PODIATRY SERVICES) • Foot Exams and Treatment • Routine Foot Care

$30 copayNot Covered


PREMIUMS AND BENEFITS

HEALTHTEAM ADVANTAGE PLAN I

WHAT YOU SHOULD KNOW

MEDICAL EQUIPMENT/SUPPLIES IN-NETWORK OUT-OF-NETWORK • Durable Medical Equipment

(e.g., wheelchairs, oxygen) • Prosthetics (e.g., braces,

artificial limbs) • Diabetes Supplies

20% of the cost

20% of the cost

$0 copay

30% of the cost

30% of the cost

20% of the cost Limited to the following manufacturers: Freestyle, Precision, and One Touch.

Wellness Programs (e.g., fitness) $0 copay $30 copay Access to Silver and Fit network facilities.

Members can change locations once per month.

Medicare Part B Drugs 20% of the cost 30% of the cost

OUTPATIENT PRESCRIPTION DRUGS

Retail Rx 30-day supply

Mail Order 90-day supply

PHASE 1: INITIAL COVERAGE

• Tier 1: Preferred Generics • Tier 2: Generics • Tier 3: Preferred Brand • Tier 4: Non-Preferred Drugs • Tier 5: Specialty Drugs

$4 copay$15 copay$45 copay $85 copay

33% of the cost

$8 copay$30 copay $90 copay

$170 copay 33% of the cost

Cost-Sharing may change depending on the pharmacy

you choose and when you enter another phase of the Part D benefit. For more information on the

additional pharmacy specific cost-sharing and the phases of the benefit, please call us

or access our Evidence of Coverage online.

OPTIONAL SUPPLEMENTAL BENEFITSDENTAL SERVICES ONLY • Monthly Premium $25 monthlyORAL EXAMS • Recall Exam (D0120) • Comprehensive Exam (D0150)

• Routine Cleaning (D1110)

$0 copay$0 copay

$0 copay

Up to 2 per year. 1 per year;

New Patients Only; Limited to 1 every 3 years.

Up to 2 per year.X-RAYS - (CHOOSE ONE OF THE FOLLOWING CATEGORIES EACH YEAR) • Bitewing X-Rays (D0270/

D0272/D0273/D0274) • Full Mouth X-Rays (D0210)

$0 copay

$0 copay

1 set per year.

1 set per year; Allowed once every year.

FILLINGS • Amalgam Filling - 1 surface

(D2140) • Amalgam Filling - 2 surfaces


(D2160) • Resin-Based Composite Filling

Anterior - 1 surface (D2330) • Resin-Based Composite Filling

Anterior - 2 surfaces (D2331) • Resin-Based Composite Filling

Anterior - 3 surfaces (D2332)

$35 copay

$45 copay

$55 copay

$50 copay

$65 copay

$80 copay

Up to 4 total fillings per year.

Scaling and Root Planing (D4341) $50 copay per quadrant Up to 2 quadrants per year.

Denture Adjustment (D5410/D5411)

$0 copay Total of 2 per year.

EXTRACTIONS • Erupted Tooth (D7140) • Surgical (D7210)

$40 copay$75 copay Up to 2 per year.

CROWNS • Porcelain Fused to Base Metal

(D2751) • Porcelain Fused to Noble

Metal (D2752) • Full Cast Base Metal (D2791) • Full Cast Noble Metal (D2792)

$305 copay

$320 copay

$307 copay$305 copay

Total of 2 per year. Crowns have a 6 month

waiting period.







DENTAL, VISION AND HEARING SERVICES • Monthly Premium $40 monthlyDENTAL SERVICESORAL EXAMS • Recall Exam (D0120) • Comprehensive Exam (D0150)


$0 copay$0 copay

$0 copay

Up to 2 per year.1 per year;




$0 copay

$0 copay

Limit 1 set per year.

1 set per year; Allowed once every 3 years.








$35 copay

$45 copay

$55 copay

$50 copay

$65 copay

$80 copay


Scaling and Root Planing (D4341)

$50 copay per quadrant Up to 2 quadrants per year.

Denture Adjustment (D5410/D5411)

$0 copay Total of 2 per year.






$305 copay

$320 copay



waiting period.

VISION SERVICES • Routine Eye Exam • Frames & Lenses OR Contacts

$0 copay$0 copay

1 per year.$200 coverage limit per

year. Excludes any in-store or in-office provider specials.

HEARING SERVICES • Routine Hearing

Screening Test • Hearing Aid Fitting Evaluation • Hearing Aids

$0 copay

$0 copay$0 copay

Limited to 1 per year.Up to 1 every 3 years.

$800 coverage limit every 3 years; for both ears.




PREMIUMS AND BENEFITS HEALTHTEAM ADVANTAGE PLAN II WHAT YOU

SHOULD KNOWMonthly Plan Premium $49 monthly You must continue to

pay your Medicare Part B premium.

Deductible $0 This plan does not have a deductible.

IN-NETWORK OUT-OF-NETWORKMaximum Out of Pocket Responsibility (does not include prescription drugs)

$3,100 $5,100 The most you pay for copays, coinsurance, and other costs for medical

services for the year.Inpatient Hospital Coverage Day 1: $225 copay





Our plan covers an unlimited number of days for an inpatient hospital stay.

DOCTOR VISITS • Primary Care Physician (PCP) • Specialist

$5 copay$15 copay

$30 copay$50 copay

Preventive Care $0 copay $30 copayEmergency Care $75 copay $75 copay If you are admitted to

the hospital for the same condition within 3 days, the emergency copay is waived.

Urgently Needed Services $30 copay $30 copayDIAGNOSTIC SERVICES/LABS/IMAGING • Diagnostic Radiology Service

(e.g., MRI) • Lab Services ◦ at a lab facility ◦ at outpatient hospital facility

• Diagnostic Tests and Procedures◦ at a lab facility◦ at outpatient hospital facility

• Outpatient X-Rays ◦ included with physician visit ◦ at outpatient facility

$50 - $175 copay

$0 copay$5 copay

$0 copay$5 copay

$0 copay$0 copay

$75 - $200 copay

$10 copay$25 copay

$10 copay$25 copay

$10 copay$25 copay

Prior authorization may be required for some services. Please contact the plan for

more information.

HEARING SERVICES • Medicare Covered Diagnostic

Hearing Exam • Hearing Aid • Routine Hearing Exam

$25 copay

Not Covered$0 copay

$40 copay

Not Covered$30 copay 1 per year.


SHOULD KNOWDENTAL SERVICES • Oral Exam & Cleaning • Fillings • Complete Dentures



VISION SERVICES IN-NETWORK OUT-OF-NETWORK • Medicare Covered

Diagnostic Exam • Routine Eye Exam • Eyeglasses (lenses and

frames)/Contact Lenses

$25 copay

$0 copay$0 copay

$40 copay


1 per year.Maximum benefit of $100.

MENTAL HEALTH SERVICES • Inpatient Visit

• Outpatient Group Therapy Visit

• Outpatient Individual Therapy Visit



$40 copay

$40 copay

35% of the cost

$55 copay

$55 copay

Skilled Nursing Facility (SNF) Days 1-20: $0 copay per day




Our plan covers up to 100 days in a SNF.

REHABILITATION SERVICES • Occupational Therapy Visit • Physical Therapy and Speech

and Language Therapy Visit

$10 copay$10 copay

$30 copay$30 copay

Ambulance $100 copay $100 copay Referral required for non-emergency transportation.

Transportation Not Covered Not CoveredFOOT CARE (PODIATRY SERVICES) • Foot Exams and Treatment • Routine Foot Care



MEDICAL EQUIPMENT/SUPPLIES • Durable Medical Equipment

(e.g., wheelchairs, oxygen) • Prosthetics (e.g., braces,

artificial limbs) • Diabetes Supplies

20% of the cost

20% of the cost

$0 copay

30% of the cost

30% of the cost

20% of the cost Limited to the following manufacturers: Freestyle, Precision, and One Touch.


SHOULD KNOWWellness Programs (e.g., fitness) $0 copay $30 copay Access to Silver and Fit

network facilities. Members can change locations once

per month.Medicare Part B Drugs 20% of the cost 30% of the cost

OUTPATIENT PRESCRIPTION DRUGS

Retail Rx 30-day supply

Mail Order 90-day supply

PHASE 1: INITIAL COVERAGE

• Tier 1: Preferred Generics • Tier 2: Generics • Tier 3: Preferred Brand • Tier 4: Non-Preferred Drugs • Tier 5: Specialty Drugs

$0 copay$12 copay$40 copay $75 copay

33% of the cost

$0 copay$24 copay$80 copay


Cost-Sharing may change depending on the pharmacy

you choose and when you enter another phase of the Part D benefit. For more information on the

additional pharmacy specific cost-sharing and the phases of the benefit, please call us

or access our Evidence of Coverage online.

OPTIONAL SUPPLEMENTAL BENEFITS

DENTAL SERVICES ONLY • Monthly Premium $25 monthlyORAL EXAMS • Recall Exam (D0120) • Comprehensive Exam (D0150)


$0 copay$0 copay

$0 copay





$0 copay

$0 copay

1 set per year.



HEALTHTEAM ADVANTAGE PLAN II









$35 copay

$45 copay

$55 copay

$50 copay

$65 copay

$80 copay


Scaling and Root Planing (D4341) $50 copay per quadrant Up to 2 quadrants per year.Denture Adjustment (D5410/D5411) $0 copay Total of 2 per year.






$305 copay

$320 copay



waiting period.

DENTAL, VISION AND HEARING SERVICES • Monthly Premium $40 monthlyDENTAL SERVICESORAL EXAMS • Recall Exam (D0120) • Comprehensive Exam (D0150)


$0 copay$0 copay

$0 copay





$0 copay

$0 copay

1 set per year.









$35 copay

$45 copay

$55 copay

$50 copay

$65 copay

$80 copay


Scaling and Root Planing (D4341) $50 copay per quadrant Up to 2 quadrants per year.Denture Adjustment (D5410/D5411) $0 copay Total of 2 per year.






$305 copay

$320 copay



waiting period.

VISION SERVICES • Routine Eye Exam • Frames & Lenses OR Contacts

$0 copay$0 copay

1 per year.$200 coverage limit per

year. Excludes any in-store or in-office provider

specials.HEARING SERVICES • Routine Hearing

Screening Test • Hearing Aid Fitting Evaluation • Hearing Aids

$0 copay

$0 copay$0 copay

1 per year.

Up to 1 every 3 years.$800 coverage limit

every 3 years; for both ears.


HEALTHTEAM ADVANTAGE PLAN II


If you want to know more about the coverage and costs of original Medicare, look in your current “Medicare & You” handbook. View it online at http://www.medicare.gov

or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. This document is available in other formats such as Braille,

large print or other alternate formats.

You can see our plan’s provider directory at our website at www.healthteamadvantage.com.You can see our plan’s pharmacy directory at our website at www.healthteamadvantage.com.

We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider. You can see the complete plan formulary

(list of Part D prescription drugs) and any restrictions on our website at www.healthteamadvantage.com.

HealthTeam Advantage complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

ATTENTION: If you speak Spanish or Chinese, language assistance services, free of charge, are available to you. Call 1-877-905-9216 (TTY:711).

HealthTeam Advantage cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-877-905-9216 (TTY: 711).

HealthTeam Advantage 遵守適用的聯邦民權法律規定，不因種族、膚色、民族血統、

年齡、殘障或性別而歧視任何人。

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-877-905-9216 (TTY: 711)。

H E A L T H T E A M A D V A N T A G E H E A L T H P L A N

C O N T A C T I N F O R M A T I O N

WEB ADDRESSVisit HealthTeam Advantage at www.healthteamadvantage.com.

SALES INFORMATIONProspective members should calltoll-free 1-877-905-9216 for questions related to the Medicare Advantage program from 8am - 8pm, EST, seven days a week.

HEALTHCARE CONCIERGECurrent members should call toll-free1-888-965-1965 for questions related to the Medicare Advantage program October 1 - February 14, 8am - 8pm, EST, seven days a week or February 15 - September 30, 8am - 8pm, EST, Monday through Friday (TTY 711).

TTY USERSTTY Users should call toll-free 711 for questions related to the Medicare Advantage Program.

PRESCRIPTION DRUG BENEFIT Current members should call toll-free 1-844-846-8003 for questions related to the Medicare Part D Prescription Drug program. TTY users should call 711.

MEDICARE INFORMATIONFor more information about Medicare, please call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You can call 24 hours a day, seven days a week. Or, visit www.medicare.gov on the web.

SUMMARY OF BENEFITS - HealthTeam Advantage€¦ · SUMMARY OF BENEFITS. HEALTHTEAM ADVANTAGE PLAN I...

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